Flash Lamp Pulsed Dye Laser (FPDL) is a non-ablative technology
that has an excellent reputation in vascular lesion treatment. It is
always the first line treatment for scars; these can be successfully
treated using different methods, such as ablative lasers or plastic
surgery. 43 year old Saudi female known to have body dysmorphic
disorder, had long history of repetitive plastic surgeries in different
body sites came complaining of her inappropriate body shape and
her weight planning for more plastic surgeries. Patients presented 9
months back complaining of multiple keloids at the sites of previous
plastic surgeries. PDL 585 nm was started (fluence 4.0 j/cm, pulse
width 20 ms, pulse rate 1.5 Hz). PDL showed subjective and clinically
improvement in treating keloids, decreasing the size and thickness.
Further trials are recommended to confirm our results.

Keywords: Keloids; Pulsed Dye Laser 585 nm; Body dysmorphic
disorder;

Introduction

Keloids are a common disorder of fibrosis, secondary to
dermal injury after trauma, burns, or surgical excision [1].
Histologically, they are characterized by excessive deposition of
collagen in the dermis. In contrast to hypertrophic scars, keloids
extend beyond the margin of initial injury, and also produce
symptoms such as itch, pain, and swelling [2-4].

Keloids pathogenesis is not completely elucidated, but
the abnormal biological behavior of keloid fibroblasts and the
complex process of wound healing disorders are believed to be
key factors [5].

Flash lamp pulsed dye laser (FPDL) is a non-ablative
technology that has an excellent reputation in vascular lesion
treatment. FPDLs contain a rhodamine dye excited by a
xenon flash lamp that produces light at 585-595 nm; the most
commonly used wavelength is 595 nm, near to hemoglobin and
oxyhemoglobin absorption peaks, and it is, therefore, considered
to be the most specific laser currently available for the treatment
of superficial vascular lesions [6]. Recent research indicates that
the growth of keloids is regulated by various growth factors, such
as TGF-b transforming growth factor b, CTGF (Connective Tissue
Growth Factor), VEGF (Vascular Endothelial Growth Factor), HSP-
47 (Heat Shock Protein-47), HSP-27 (Heat Shock Protein-27 ),
PDGF (Platelet Derived Growth Factor), IGF (Insulin-like Growth
Factor), IL (Interleukin), and SP (Substance P), which can all
promote the proliferation of fibroblasts and collagen synthesis
in keloids. Therefore, the above-mentioned factors play an
important and complex role in the genesis and development of
keloids [5,7,8].

Current indications of FPDL technology have been further
extended in order to include nonvascular lesions that have
vascular structural involvement, which makes them amenable
to be treated with such laser. FPDL is not always the first line
treatment for scars; these can be successfully treated using
different methods, such as ablative lasers or plastic surgery.
Potential adverse events include post-inflammatory pigmentary
changes (especially in darker-skinned patients, immediate
post-laser purpura, recurrence, and infection. Sun exposure
can drastically affect pigmentary changes, and sun avoidance/
protection is essential to optimizing outcomes [6].

The Case report

This case is 43 year old Saudi female, not known to have any
medical illness, known having Body Dysmorphic Disorder (BDD)
and had long history of repetitive plastic surgeries in different
body sites (both axillae, lower and mid abdomen, under breasts
folds). The patient came complaining of her inappropriate
body shape and her weight planning for more plastic surgeries.
Patients presented 9 months back complaining of multiple
keloids at the sites of previous plastic surgeries (erythematous
and hyperpigmented soft plaques and nodules), also complaining
of associated pruritus and discomfort. These keloids were present
over the previous plastic surgeries scars (axillae, lower abdomen,
umbalical, and lower breast). Their size ranged between 1 and 10
cm whereas their thickness ranged between 1and 10 mm. They
progressively increase in size but not in umber. Patient started on
Silicon Gel (Figure 1) two times per day for 2 months but patient
mentioned no improvement at all which made her more irritated
about her look.

Figure 1: Silicon gel used twice per day

On the next visit, she was asking about other line of treatment
and was depressed about her skin problem. So PDL 585 nm
(Figure 2) was started (fluence 4.0 j/cm, pulse width 20 ms, pulse
rate 1.5 Hz).

Figure 2: PDL machine used in our clinic

Preparation of Laser involved patient consent with complete
explanation of the procedure and possible complications and
side effects, patient was lying over laser bed exposing the sites
of keloids, eye protective equipment were used for the patient
and laser protective glasses were used by the doctor and
assistant (Figure 3). The patient had four sessions between each
session and the other a duration of 4 weeks. Patient mentioned
improvement in the keloids size after the second session with
obvious shrinking clinically (decreasing in size, after the fourth
session it was hyperpigmented flattened plaques). Results of the
laser sessions are shown in (Figures 4 and 5). No side effects or
complications were documented. Patient was not known to have
any allergies and no same family history of keloids.

As Ablative laser were known to be used as a line of treatment
for keloids we tried PDL for our patient. PDL is usually used for
vascular associated disorders like capillary malformation.

We considered in our study that the PDL is targeting the
cutaneous blood vessels and its proliferations at the sites of
keloid malformation. After using the PDL we observed clinically
that the keloid thickness and size were decreasing. The patient
was tolerating the Laser session with no complains. Patient
psychological status was improved and patient was satisfied.

Al-Mohamady et al concluded in their study that PDL and
long-pulsed Nd: YAGlaser treatments for hypertrophic scar and
keloids showed significant improvements with no difference
between the two modalities [9]. However in analysis of the results
of 102 cases, the response of hypertrophic scars to 1064 nm Nd:
YAG laser treatment was better than keloids [10].

Akaishi et al revealed that Nd:YAG laser treatment is very
effective in the treatment of keloids and hypertrophic scars
regardless of the origin and multiplicity of scarring, the location
of the scar(s), patient age, or the tension on the scar [11].

Among important effects of lasers in treating scars is the
fact that laser generate heat, which begins inflammation and
in turn raises vascular permeability, matrix metalloproteinase
production, and collagen fiber fascicle decomposition [12,13].

Conclusion

PDL showed subjective and clinically improvement in treating
keloids, decreasing the size and thickness. Further trials are
recommended to confirm our results.